King v. Burwell: Frequently Asked Questions

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February 26, 2015
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Q: What is the issue being addressed in King v. Burwell?
A: King v. Burwell is about whether all people who purchase health insurance under the Patient Protection and Affordable Care Act are eligible to receive subsidies – or, as the challengers would have it, only residents of those 13 or so states who set up their own healthcare exchanges. Without these subsidies, many low and middle income people will not be able to afford health insurance, which of course would defeat Congress’s purpose in passing the Affordable Care Act.

Q: How would a negative decision affect people living with HIV?
A: The great majority of HIV-positive people in the States affected make less than 400% of the poverty level, would become ineligible for subsidies and will no longer be able to afford health insurance. Without health insurance, they may no longer have access to the life-saving medication and care they need.

Listen to our teleconference with Lambda Legal Counsel Greg Nevins and HIV Project Director Scott Schoettes, "King v. Burwell at the Supreme Court":

Q: If people with HIV are no longer able to afford health insurance, couldn’t they just fall back into the old system of HIV care?
A: We couldn’t easily return to that system and we wouldn’t really want to do so. In addition to the fact the old system of HIV care is already adapting and changing to work alongside Obamacare, the truth is that the old system wasn’t working that well. Despite the hundreds of millions of dollars spent on this system over the past 25 years, in 2011 only 28% of the more than 1.1 million people living with HIV in the United States had achieved viral suppression. As recently as a few years ago, there were waiting lists to get HIV drugs in several states, and those are the very states whose residents would lose their subsidies if this legal challenge is successful.

Q: Why does Lambda Legal’s brief focus upon communities of color?
A: Within the states potentially affected by the decision in this case, there is a veritable public health emergency going on within communities of color when it comes to HIV. In this country, a Black person is 8 times more likely to contract HIV than a white person, and after infection has a 13% greater chance of an AIDS-related death. If we don’t correct course, these disparities are only going to get worse. Lambda Legal thought it important to bring these racial disparities to the Court’s attention and to provide a legal framework in which the Justices could take them into account while making their decision about Congress’s intent in passing this legislation.

Q: So lack of access to healthcare for people of color increases susceptibility to HIV infection. Are there behavioral differences at work also?
A: No, it seems not. For instance, multiple epidemiological studies have shown that black gay and bisexual men engage in the same or less risky behavior than their white counterparts. There is, however, another factor that plays into higher rates of new infection within certain communities: the tendency of people towards same-race sexual partners. Certain communities have a higher percentage of people with HIV, and when the percentage of people with HIV within the pool of potential sexual partners is higher, the chances of contracting HIV increase accordingly. Layer on top of the lower testing and treatment rates within communities of color and the fact that transmission is more likely to occur if people do not know they are HIV-positive or are not able to access treatment, and it is easy to see the snowball effect that leads to the significantly higher prevalence of HIV within certain communities.

Q: How would an adverse decision affect people who are trying to stay HIV-negative?
A: Profoundly. The The federal Ryan White HIV/AIDS Program doesn’t cover medications for people who are HIV-negative, so it doesn’t provide health insurance that would cover Pre-Exposure Prophylaxis (PrEP), which has been shown to be highly effective in preventing HIV transmission. Also, limited access to healthcare for people of color historically has led to much higher rates of untreated sexually-transmitted infections, which in turn greatly increases susceptibility to HIV.

Q: If the U.S. is one of the wealthiest countries in the world, and the place where most of these very effective HIV medications have been developed, why are people still dying here?
A: There are a number of contributing factors, but the primary reason is that healthcare had not previously been made affordable and accessible to everyone in this country. We have the medical infrastructure to deliver this care, we have medications that turn HIV into a chronic, manageable condition, and we now have multiple effective methods of preventing its transmission. But only with the passage of the Affordable Care Act did we as a country make this a priority and muster the political will to make affordable healthcare a reality. And only with the preservation of the ACA can we achieve our goal of an AIDS-free generation.